Please read the page that is entitled FAMILY MEDICINE CENTER for guidelines on exclusivity by 59hl91hv


                                         RRC FOR FAMILY MEDICINE
                                        515 N. State Street, Suite #2000
                                               Chicago, IL 60654

                      Proposal for a New or Additional Family Medicine Center (FMC)

Title of Program:

10 digit ACGME Program ID #:

The signatures of the program director and the designated institutional official (DIO) attest to the
completeness and accuracy of the information provided on these forms.

Name of Program Director:

Signature of Program Director and Date:

Name of Designated Institutional Official:

Signature of Designated Institutional Official
and Date:

Attached to this proposal are guidelines for your use. Answer all parts that are relevant. Refer to the
Program Requirements, effective July 1, 2007. Please submit the full proposal in duplicate.

Please check with the RRC office regarding the date by which the information should be
submitted. To be included on an RRC agenda, proposals must be received in the RRC office
2-3 months in advance of the meeting. Do not assign residents to an unapproved site.

If this is a proposal for use of a federally designated Community Health Center (CHC), provide full
details about its use and identify clearly the separate pod that will be used for the FMC. Include a
description of how and by whom on-site supervision will be provided that indicates compliance with the
requirements. Documentation of the authority of the program director over the educational activities
must be provided. See Program Requirements and the attached guidelines on pages 10-11.

If this FMC will result in a change of mailing address for the Program Director, provide the new
mailing address, phone number, fax number and e-mail address in ADS on the ACGME website.

Answer questions 1 and 2 in the text boxes below.

1.      State whether this is a proposal for an additional FMC or for relocation of an existing facility.
        Give the rationale for opening an additional or new FMC and the proposed date of

2.      If this is a relocation from an existing site, explain whether the patient population will remain
        the same or the residents’ continuity experience will be interrupted.

If this is a proposal for an additional FMC, explain how many and in what years of training
residents will be assigned. If PGY-2 or PGY-3's are involved, address how they will be able to
maintain continuity for a patient panel for two consecutive years, as is required by both the

                                 PROPOSED FAMILY MEDICINE CENTER

Name of Center:
Total resident complement in program by PGY (e.g.,
Number of residents that will be assigned to this
FMC by PGY (e.g., 2-2-2):
Name of Director of FMC:

Attach (behind this page on a sheet no larger than 11” X 17”) a legible drawing of the floor plan of the FMC.
Where multiple centers are used, put the name and FMC # on each drawing. Label each room to indicate its
function. Be sure that all required areas are clearly identified according to the key below. If any required
areas are missing, identify the required area and explain. Please read the page that is entitled
FAMILY MEDICINE CENTER for guidelines on exclusivity. Demonstrate clearly on your diagram that
the FMC is separated appropriately from other activities.

If the drawing is illegible, the RRC will not be able to evaluate the proposal. Do not submit a reduced
copy of a blueprint.

Please use the key provided below to identify the required areas on the FMC drawing. Use sufficiently large
letters and numbers that are easily recognizable on the drawing.

A = waiting room
B = reception/appointment desk for FMC only
C = business office
D = records (if an EMR is not used)

1 = exam rooms (provide total number of rooms on the drawing)
2 = office lab
3 = office library
4 = resident work area
5 = precepting room
6 = other (identify and explain)
7 = conference room
8 = faculty offices

If any of these required components is not included in the FMC, provide an explanation below including
specific details regarding location and proximity to FMC.


1. List all the FMCs that will be used by this program. The numbering of the FMCs should be consistent with the information provided at the
time of the last review. The new or additional FMC being proposed should appear last. If this is a relocation, specify which FMC it replaces.

           NAME of FMC                                                                                                                               Miles from primary hospital/travel time
FMC #1
FMC #2
FMC #3
FMC #4
FMC #5

2. Complete the row in the table below for the proposed FMC(s) only.

                                                                                                                                                                                                                                Number of FMC

                                                                                                                                                                       faculty seeing patients in
                                                                                                                                                                       Maximum # of resident &
                                                                                                                             FM preceptor:resident

                                                                               Scheduled operating

                                                                                                      Square feet of floor

                                                                                                                                                                       FMC simultaneously

                                                                                                                                                                                                    # of other learners
                                                                                                                                                     # of exam rooms
                                                                                                      space available

                                                                                                                                                                                                                                                           Other (specify
                                                                                                                                                                                                    in FMC*



                      Name of FMC                 Name of FMC Director
Example Johnston FMC                              Tom Smith, MD             8-8 (M-F)                10,000                  1:4                     16                           8                 MS=2                  10        8          NA              NA
                                                                             8-1 (S)                                                                                                                OP=1
FMC #1
FMC #2
FMC #3
FMC #4
FMC #5
*specify the type and number of other learners in the FMC. Use the following categories: medical students=MS; other residents = OR; nurse practitioners =
NP; other professionals=OP, e.g. dentists, podiatrists.

   Other Personnel in the FMC: Please specify

Answer the following questions for the                FMC #1        FMC #2        FMC #3        FMC #4        FMC #5
proposed FMC(s) only. Make sure that you
complete the correct column.
3. Answer YES or NO to the following.
    a. Does the entry to the FMC have signage
       that clearly identifies it as an FMC?
    b. Does the residency director have control
       of the education activities in the FMC?
    c. Does the residency director have control
       of the activities of the support personnel
       in the FMC?
    d. Does the director of the FMC report to the
       program director?
    e. Does the appointment system assure
       maximum accessibility of the resident to
       his/her patients in the FMC?
    f. Is there a business office or business
       function area in the FMC?
    g. Is there a conference room large enough
       to accommodate the residents, faculty,
       etc., at this FMC?
    h. Do FMC patients have convenient access
       to imaging services?
    i. Do FMC patients have convenient access
       to a diagnostic laboratory?
    j. Do patients have access to a program
       physician after hours?
    k. Do family physician faculty see patients
       without residents in the FMC?

4.     For any NO answers in question 3, identify the point and provide an explanation or description.

5.     Describe in detail any activities that take place in the FMC that are not FM residency related.

6.     If other specialties are located on the same floor of the facility, explain and demonstrate on the floor plan how
        the FMC is a discrete unit that is separate from these areas.

7.     Specify any other space currently allocated for administrative offices, conferences, etc., for residents/faculty
       assigned to this FMC which is not a part of the FMC.

8.      If multiple Family Medicine Centers are used, describe the following:

        a.      How residents are assigned to the Centers and whether the assignments are for all three years of
                training. If not, provide specific details about levels of training involved.

        b.        The degree of contact among the residents from the multiple centers.

9.      Provide the following information on the record system:

        a.        What kind of system is used? If an electronic medical record is not used currently, what are the
                  program’s plans for implementing one in the near future?

        b.        If an EMR system is not used, explain how patients' ambulatory records are maintained in the FMC
                  and how easy and prompt accessibility to these records is ensured.

        c.        Do patients' records contain documentation of all facets of family care, including care provided in the
                  FMC, hospital, home, via telephone and in other institutions? If NO, explain.

        d.        Do the residents have easy access to the FMC records 24 hours a day? If NO, explain.

10.   Describe the system that is in place to audit FMC charts on a regular basis. If there is no system, explain.

11. Submit information on practice demographics (age/sex register), if known.

                Age            Percentage of Total Visits Number of Female Visits             Number of Male Visits

              Under 2


               10 – 19

               20 – 29

               30 – 39

               40 – 49

               50 – 59

               60 – 69

             70 and over

FMC Patient Population

1.   If the proposed facility has been used as a faculty practice, provide actual data for a one year period, as

        a. Inclusive dates for which the information is provided: July 1, 20        to June 30, 20

        b. Total number of patient visits to FMC last year:

        c. Number of FMC patients admitted to the hospital last year:

        d. Percentage of these patients that will be available for resident education:

2.   For use of an additional FMC or relocation of an FMC that has not been in operation, provide specific details
     of the anticipated source and size of the patient population during the first year of operation.

Primary and Participating Hospitals

   Complete this page if patients will be hospitalized at a facility not currently approved as part of the residency.

    Name and # of Hospital:
    Inclusive dates for the following
                                                  From:                                 To:
    Hospital    Total number of                                                         Average daily
    statistics: available beds:                                                         census:

   If this facility is different from the teaching site of the residents’ required rotations, explain the logistics of how they
   will provide continuity of care at one site while rotating to another.

   Complete this section only for services on which there are required rotations in this institution.

                                                                                              # of
                         # of MD/DOs Annual # of   # of                                                      Annual # of
                                                                                           MD/DOs on
                            on Staff Discharges Deliveries                                                   Discharges
    Family Medicine                                                     (excl.
    Internal Medicine                                      xxxxxxxx     Newborns
                                                           xxxxxxxx     Surgery

   If the primary hospital has fewer than 135 occupied beds, provide an explanation below. The explanation should
   include: a description of the types of patients and spectrum of disease, the availability of support services including
   physical, human and educational resources and average number of patients per resident on the service. Describe
   any additional experiences that compensate for the low patient numbers at the primary hospital.

Family Physician Faculty

    List the family physician faculty who contribute 200 or more hours per year to the residency. Time devoted to the
    department that is not residency-related should not be included. List full time first, then part time paid participants,
    and last the volunteer faculty. The RRC considers faculty that contribute a minimum of 1400 hours to the residency
    as full time.

    Column A: Time reported here reflects contact hours with residents in the Family Medicine Center, on the inpatient
    service, in private offices and other clinics or facilities. This may include time spent in residency administration. On-
    call and weekend time does not count. For inpatient rounds, count only time spent with residents. One faculty
    contact hour should be counted as one hour no matter how many residents are involved. Also identify the FMC
    (see page 3) in which each faculty member functions or will function.

    Column B: Time reported here reflects the degree to which role modeling occurs in the FMC. It may not be
    included in the time committed to the residency.

                                                                                        A                        B
                                                                       Total Hrs/Yr
                                                                      Devoted to FM
                                                                           -------                        Hrs/Yr Seeing
                                      Name of Board Date of Most Identify FMC at which                   Patients in FMC
                                       (If Currently    Recent       faculty member                          Without
            Name, Degree                 Certified)  Recertification    functions                          Residents
    Example:                                                               1400
                                           ABFM          2006                                                   200
    Paulik, Jas, MD                                                      FMC #1
    Program Director:

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                                             FAMILY MEDICINE CENTER

        The following is a statement of what the RRC expects of a facility that will function as a Family
        Medicine Center* within an accredited residency program:

                Family Medicine Center - A Discrete Unit

                This is the model unit that must be contained within walls and is clearly identified as the
                Family Medicine Center on the door of entry to this unit. When one enters the door of the
                FMC, one finds all of the components that are listed as required, and nothing else. That is,
                there are no non-residency related activities taking place within the walls of the FMC.

                While this unit may be on the same floor as other specialty clinics or private practices, it
                must be a discrete unit that is separated from those activities by walls.

                Family Medicine Center - Other Participants

                The requirements state that non-residency activities may not take place in the Family
                Medicine Center. Family physicians may have their offices in the FMC only if they are
                identified as teaching faculty who contribute at least 400 hours per year to the residency.

                Physicians from other specialties** may have offices in the FMC, in which they see private
                patients, if they contribute at least 1400 hours per year to the family medicine residency
                and no more than 600 hours is devoted to seeing their own private practices in the FMC
                without FM residents.

                Other clinics, such as occupational medicine, may take place in the FMC if these activities
                are directed by the family medicine faculty and exist for the purpose of teaching the family
                medicine residents.

                Accredited programs in Family Medicine Sports Medicine and in Family Medicine-Geriatric
                Medicine may take place in the FMC.

                *       Programs utilizing Community or Migrant Health Centers should refer to section III.
                        D.2.a in the Program Requirements (effective July 1, 2006).

                **      If a private practice is used as the FMC for the rural component of a 1-2 program,
                        all of the physicians in the practice must be actively involved in the education of
                        the Family Medicine residents. Their involvement in the teaching program must be
                        documented by the Program Director at the time of each review. Because of the
                        small number of residents at the rural site, the faculty need not contribute the
                        hours listed above to the program.

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                                        USE OF COMMUNITY HEALTH CENTERS

        The following are guidelines for program directors who propose using a Community Health Center as a
        Family Medicine Center. The RRC will focus on these points in the evaluation of such proposals.

        1.      The program director must have authority and responsibility for the educational program of the
                residents and be able to ensure that the Program Requirements are met. Documented evidence
                that the program director will have sufficient control over the educational activities in the CHC must
                be provided. This should involve assurance of control over the numbers of patients that will be
                seen by residents and their assignment to resident panels in family groups (appointment system),
                hospitalization of patients where residents can follow them under the supervision of program
                faculty, hours of operation, etc. A signed agreement between the Board of the CHC and the
                residency must be submitted with the proposal.

        2.      The facility must have all of the areas specified in the Program Requirements for a Family
                Medicine Center. If the space utilized by the residency in the CHC is not designated for the
                program’s exclusive use, the program must provide evidence that the integrity of the educational
                program will be preserved. The RRC will determine the acceptability of the proposed

        3.      The appointment and assignment of faculty preceptors in the CHC must be under the control of the
                program director who must ensure the presence of qualified faculty, to monitor their development
                and evaluation and to ensure their availability for the needs of the residency. The requirements for
                preceptor availability are the same as for FMC’s.

        4.      Residents and patients in the CHC must have access to adequate laboratory and imaging facilities
                as well as to other required clinical services and consultation, as expected in any Family Medicine

        5.      The support staff of the CHC (nursing, billing, clerical) must be adequate for service and education.

        6.      The patient charts and record system must be adequate and in compliance with the requirements
                for 24-hour accessibility, documentation of resident experience, audits, etc.

        7.      Residents must be able to admit and care for their continuity patients, including obstetrical patients
                and those in nursing homes, who are hospitalized from the CHC and patients must have access to
                their physicians or designated substitutes after clinic hours.

        8.      Behavioral science education must be integrated into the residents’ experiences in the CHC in the
                manner that is expected in all FMC’s.

        9.      There must be adequate peer interaction among residents who are assigned to the CHC as well as
                formally structured mechanisms for the integration of these residents into the full residency. This
                must involve an initial period of orientation as well as regular attendance at conferences.

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